Provider Demographics
NPI:1053609552
Name:DOMENICI, KATHERINE MARY (DPT)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARY
Last Name:DOMENICI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 RUNNELLS RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03303-3908
Mailing Address - Country:US
Mailing Address - Phone:603-209-2042
Mailing Address - Fax:
Practice Address - Street 1:134 HALL ST UNIT 1
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-3470
Practice Address - Country:US
Practice Address - Phone:603-224-4540
Practice Address - Fax:603-228-7384
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3625225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1053609551Medicaid